d’Unienville 

et al. J Int Soc Sports Nutr (2021) 18:76

https://doi.org/10.1186/s12970-021-00472-y

REVIEW Open Access

Effect of food sources of nitrate,

polyphenols, L-arginine and L-citrulline
on endurance exercise performance:
a systematic review and meta-analysis
of randomised controlled trials
Noah M. A. d’Unienville1,2*  , Henry T. Blake1,2  , Alison M. Coates1,2  , Alison M. Hill2,3  ,
Maximillian J. Nelson1,2   and Jonathan D. Buckley1,2   

Abstract 
Background:  Increasing nitric oxide bioavailability may induce physiological effects that enhance endurance
exercise performance. This review sought to evaluate the performance effects of consuming foods containing com-
pounds that may promote nitric oxide bioavailability.
Methods:  Scopus, Web of Science, Ovid Medline, EMBASE and SportDiscus were searched, with included studies
assessing endurance performance following consumption of foods containing nitrate, L-arginine, L-citrulline or poly-
phenols. Random effects meta-analysis was conducted, with subgroup analyses performed based on food sources,
sex, fitness, performance test type and supplementation protocol (e.g. duration).
Results:  One hundred and eighteen studies were included in the meta-analysis, which encompassed 59 polyphenol
studies, 56 nitrate studies and three L-citrulline studies. No effect on exercise performance following consumption
of foods rich in L-citrulline was identified (SMD=-0.03, p=0.24). Trivial but significant benefits were demonstrated
for consumption of nitrate and polyphenol-rich foods (SMD=0.15 and 0.17, respectively, p<0.001), including perfor-
mance in time-trial, time-to-exhaustion and intermittent-type tests, and following both acute and multiple-day sup-
plementation, but no effect of nitrate or polyphenol consumption was found in females. Among nitrate-rich foods,
beneficial effects were seen for beetroot, but not red spinach or Swiss chard and rhubarb. For polyphenol-rich foods,
benefits were found for grape, (nitrate-depleted) beetroot, French maritime pine, Montmorency cherry and pome-
granate, while no significant effects were evident for New Zealand blackcurrant, cocoa, ginseng, green tea or raisins.
Considerable heterogeneity between polyphenol studies may reflect food-specific effects or differences in study
designs and subject characteristics. Well-trained males (V̇O2max ≥65 ml.kg.min-1) exhibited small, significant benefits
following polyphenol, but not nitrate consumption.
Conclusion:  Foods rich in polyphenols and nitrate provide trivial benefits for endurance exercise performance,
although these effects may be food dependent. Highly trained endurance athletes do not appear to benefit from

*Correspondence: Noah.D’Unienville@unisa.edu.au
2
Alliance for Research in Exercise, Nutrition and Activity (ARENA),
University of South Australia, Adelaide, Australia
Full list of author information is available at the end of the article

© The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
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d’Unienville et al. J Int Soc Sports Nutr (2021) 18:76 Page 2 of 28

consuming nitrate-rich foods but may benefit from polyphenol consumption. Further research into food sources,
dosage and supplementation duration to optimise the ergogenic response to polyphenol consumption is warranted.
Further studies should evaluate whether differential sex-based responses to nitrate and polyphenol consumption are
attributable to physiological differences or sample size limitations.
Other:  The review protocol was registered on the Open Science Framework (https://​osf.​io/​u7nsj) and no funding was
provided.
Keywords:  Nitric oxide, nitrate, polyphenols, l-citrulline, antioxidants, foods, supplements, endurance, athletes

Background [11]. While the increase in ROS during exercise is an

Nitric oxide (NO) is a signalling molecule that is involved
in numerous physiological processes including skeletal
muscle contraction [1], endothelial function [2], mito-
chondrial biogenesis and respiration [3], muscle repair
[4] and antioxidant defences [5–7]. Given these func-
tions are important during exercise, particularly aerobic
exercise, there has been considerable interest in enhanc-
ing NO production to improve endurance exercise per-
formance. Specifically, increased synthesis of NO is
proposed to reduce the oxygen cost of ATP resynthesis,
lower the ATP cost of cross-bridge formation and pro-
mote vasodilation, thereby enhancing skeletal muscle
blood flow and oxygen perfusion which may speed oxy-
gen uptake kinetics [8]. These effects may translate to
increased endurance exercise performance by improving
exercise efficiency, decreasing the oxygen deficit at exer-
cise onset and reducing the V̇O2 slow component [9].
NO is synthesised through two pathways, one of
which is nitric oxide synthase (NOS)-dependent and one
which is independent of NOS. NO is synthesised via the
NOS-dependent pathway from L-arginine and oxygen
in a reaction that is catalysed by various NOS enzymes,
including endothelial nitric oxide synthase (eNOS). L-cit-
rulline, an α-amino acid, also contributes to NO synthesis
through this NOS-dependent pathway via its conversion
to L-arginine. Polyphenols may enhance NO production
by increasing eNOS expression and activity [10] and pro-
mote NO bioavailability via their antioxidant effects pro-
tecting NO from breakdown by reactive oxygen species
(ROS). Within the NOS-independent pathway, nitrate
­(NO3-) is reduced to nitrite ­(NO2-) and then NO. Thus,
it is proposed that NO availability may be improved by
increasing the availability of N ­ O3-, ­NO2-, L-arginine,
L-citrulline, or polyphenols. Such changes in NO bio-
availability are typically evaluated by plasma or urine
­NO3- and ­NO2-, as these are end products of endogenous
NO production, but can also be inferred via measures of
vascular function such as flow-mediated dilation (FMD).
In addition to the effects of polyphenols on NO synthe-
sis via the NOS-independent pathway, their antioxidant
properties have also been proposed to promote exer-
cise performance by helping to maintain redox balance
important signalling component that can facilitate acute
responses and chronic adaptations to exercise, an imbal-
ance between oxidative stress and antioxidant capacity
may lead to impairment in blood flow, calcium handling
and sensitivity, and central neural drive [11–13]. These
derangements may contribute to the development of
fatigue during exercise, so increasing antioxidant capac-
ity may assist in inhibiting the onset of fatigue and
enhance athletic performance. Thus, increased consump-
tion of dietary polyphenols may enhance endurance exer-
cise performance through effects on the NOS-dependent
pathway and antioxidant capacity during exercise.
Augmentation of NO synthesis and bioavailability has
been attempted by increasing the dietary intake of NO
precursors. ­NO3- is abundant in beetroot and green leafy
vegetables such as lettuce and spinach [14] and L-argi-
nine is found in seafood, nuts, seeds, soy protein isolate
and watermelon. Watermelon is also a rich source of
L-citrulline, while fruits, vegetables, tea, coffee and cocoa
are rich sources of polyphenols [15]. ­NO2-can be found in
some fruits and vegetables, with more pronounced con-
centrations found in processed meats where it is used as
an additive [16]. Many foods contain a combination of
these nitric oxide precursors, as well as other antioxidant
components such as vitamins, minerals and carotenoids,
with interactions between these various phytochemicals
and food sources potentially resulting in varied responses
to specific foods and/or combinations of foods [17–19].
There appear to be considerable inter-individual dif-
ferences in bioavailability in response to consumption of
polyphenols [20] and ­NO3- [21, 22]. Several factors may
influence the content and bioavailability of polyphenols
in foods, such as storage and processing methods [23],
the food matrix, and in particular, the profile of specific
polyphenol subclasses (e.g. anthocyanidins vs quercetin)
which vary significantly in their absorptive characteris-
tics [20, 24]. Bioavailability is also affected by background
diet, genetic factors, and particularly intestinal micro-
biota, as most polyphenols are catabolised by bacteria
in the large intestine and the catabolites then enter the
circulation and exert antioxidant effects [19, 25]. Simi-
larly, the composition of ­ NO3--rich food sources and
 d’Unienville et al. J Int Soc Sports Nutr (2021) 18:76
microflora of the oral and gut microbiome may impact
­ O3- from N
the bioavailability of N ­ O3--rich foods [22].
While increasing NO production may improve endur-
ance exercise performance, performance effects may
also be influenced by sex and fitness-related differences
in NO synthesis [26, 27], vascular function [28, 29] and
oxidative damage [30, 31]. Thus it is important to evalu-
ate whether the effects of consuming foods that increase
NO production on endurance exercise performance are
influenced by these individual factors, as well as other
parameters such as type of exercise performance test per-
formed, the intensity at which the test is performed, and
the dose and duration of consumption of NO precursors.
The primary aim of this systematic review and meta-
analysis was to evaluate whether consumption of foods
rich in precursors of NO synthesis improves endurance
exercise performance. A secondary aim was to determine
the effect of dose and duration of consumption of foods
rich in NO precursors, participant characteristics (fitness
and sex) and exercise test parameters (type and intensity)
on exercise performance.
Methods
Information sources and search strategy
A literature search was conducted using the Scopus,
Web of Science, Ovid Medline, EMBASE and Sport-
Discus databases on 5 September 2019. Title, abstract,
keyword and MeSH (where applicable) searches were
implemented.
The search terms are provided in Additional Material 1,
but in brief, search terms were grouped under:
1. Population (e.g. human, athlete).
2. Compounds that promote nitric oxide synthesis (e.g.
­NO3-, polyphenols) and food sources of these com-
pounds (e.g. beetroot juice, blackcurrant).
3. Terms related to maximal endurance performance
(e.g. exercise tolerance, time-trial).
Articles included in the search were exported to End-
note reference management software (Version 9, Clari-
vate Analytics, Philadelphia, PA), where duplicates were
removed before remaining studies were uploaded to Cov-
idence systematic review management software (Veritas
Health Innovation, Melbourne, Australia).
Registration and protocol
A protocol application was submitted to PROSPERO
on the 4­th of September 2019, but we were informed
that it was unsuccessful on the ­29th January 2020 as it
was not considered within their scope. Thereafter, the
authors became aware of the Open Science Framework,
where the study was registered on the 5­ th February 2020
Page 3 of 28
(accessible at https://​osf.​io/​u7nsj), which was after the
title and abstract screening had been completed, but
before full-text review had been completed by NMAdU
or started by HTB.
Eligibility criteria
Studies were limited to human participants and Eng-
lish language, peer-reviewed studies, with no limit set
on publication date. Studies needed to increase dietary
intake of compounds that promote nitric oxide synthe-
sis and bioavailability, with such compounds including
polyphenols, ­NO2-, ­NO3-, L-citrulline and L-arginine,
and adhere to the inclusion and exclusion criteria listed
in Tables 1 and 2 respectively.
Study selection
During title and abstract screening, studies were
excluded if they were not consistent with the inclusion
and/or exclusion criteria. Antioxidant supplements or
nutrients from an unspecified source were deemed eli-
gible at this stage, as during preliminary searches it was
noted that these types of articles sometimes specified a
polyphenol food source from which the supplements or
nutrients were obtained in full texts. Full-text articles
were then screened to ensure that studies met the eligi-
bility criteria. For inclusion in the meta-analysis, studies
needed to report data that would enable calculation of a
standardised mean difference (SMD).
Title and abstract screening and full-text review were
conducted independently by two reviewers (NMAdU
and other authors excluding JDB for title and abstract,
NMAdU and HTB for full text), with disagreements
regarding eligibility settled by a third reviewer (JDB).
Where full texts were unavailable, they were sought from
the authors, and reference lists were also pearled to iden-
tify additional relevant studies.
Data collection process and items
The data extraction form was drafted by the lead author
(NMAdU), and studies were extracted in duplicate by
NMAdU and HTB. Extracted information included
date of publication, industry contributions, population,
anthropometry, inclusion/exclusion criteria, supplement
composition, dosing and duration of supplementation,
performance test(s) and outcomes, dietary restriction of
other foods or nutrients, and effects on biochemical and
physiological markers of nitric oxide production.
Risk of bias assessment
Risk of bias in individual studies was assessed using the
Revised Cochrane risk-of-bias tool for randomized trials
[33] by the lead author (NMAdU) and a second author
(HTB), with partial duplication to ensure consistency.
d’Unienville et al. J Int Soc Sports Nutr (2021) 18:76
Table 1  Inclusion criteria
Inclusion criteria
Consumption of nitric oxide precursors only via consumption of whole
foods, juices, concentrates or plant extracts. Studies must explicitly state
the food source(s) of these compounds.
Foods could not be consumed in combination with other (non-nitric oxide Confounds the ability to infer the effect of increasing intake of nitric-oxide
precursor) foods/supplements that may influence endurance exercise
performance (e.g. caffeine) unless the comparator group also contains
these components. Such interventions will be included in the qualitative
synthesis only.
Report an external (or externally derived) measure of maximal endurance
exercise performance in a test of at least two minutes durations.
Intermittent-type performance tests required a work duration of at least
two minutes and could not have between-repetition recovery intervals of
>60 secs
Performance tests conducted in normobaric, normoxic and temperate
conditions.
Where performance tests were acutely repeated (e.g. repeated time trials),
only data from the initial performance test were considered eligible.
Study sample participants aged 18-65 years
Table 2  Exclusion criteria
Exclusion criteria
Performance assessed during recreational, open entry events (e.g. mara-
thon)
Performance only measured as an indicator of recovery (e.g. hours or days To reduce the influence of post-exercise recovery, which reflects a different
following an exercise stimulus designed to induce damage/stress) rather mechanism
than being assessed at maximum performance capacity or more closely
following a standardised preload
Treatment comparator was a food rich in nitric oxide precursors (unless
differences in content are quantified)
Supplement contained >1mg caffeine per kg of body mass, as calculated
from participant mean mass
Performance test intensity was acutely regulated by heart rate or oxygen
consumption.
Risk of bias was evaluated through visual inspection of
standard and contoured funnel plots.
Effect measures
The effects of nitric-oxide related supplements were
assessed using endurance exercise performance out-
comes. Studies frequently reported multiple performance
outcomes from the same performance test (e.g. mean
power and time-to-complete reported for a time-trial).
Therefore, where applicable, time-to-complete was the
extracted outcome used for data analysis from fixed dis-
tance/work time-trials, while total distance/work was
preferentially extracted for fixed duration time-trials.
Likewise, peak power/speed was designated as the pri-
mary outcome from graded exercise tests, and total
Page 4 of 28
Rationale
Differences in bioavailability between food and synthetic sources.
precursors.
Maximise the contribution of the aerobic energy system to exercise per-
formance and thus provide a measure of endurance exercise performance.
Maximise the contribution of the aerobic energy system to exercise per-
formance and thus provide a measure of endurance exercise performance.
Variant conditions may influence the function of the nitric oxide pathway
and the effects of nitric oxide-related supplementation
Performance in subsequent trial(s) may be confounded by initial perfor-
mance and factors which influence recovery.
Exclude adolescent and older adult populations due to age-based differ-
ences in vascular function and oxidative stress
Rationale
Lack of controlled conditions
Difficult to infer how much treatment increases nitric oxide precursors
relative to control
Avoid ergogenic effects seen with higher intakes of caffeine [32]
Nitric oxide supplements may alter these internal measures and thereby
confound the ability to identify effects on endurance exercise performance.
distance/work was extracted as the primary outcome for
intermittent tests. Relative mean or peak power outputs
were used in favour of absolute values.
Effect size was quantified as the SMD, where the mean
difference between treatments was divided by the
pooled standard deviation, with Hedge’s correction fac-
tor also applied to adjust for small sample sizes [34].
Where performance was assessed before the active and
control interventions in parallel trials, SMD was instead
calculated from mean change (from baseline) values and
standard deviations. Where SD of these changes was
unavailable, it was imputed for each group as
using a cor-
√ ( )
SDchange = SD2 + SD2 − 2 × 0.80 × SDbaseline × SDfinal
baseline final
relation coefficient of 0.80 (35, 36). A factor of -1 was
applied to SMDs for time to complete to ensure consist-
ent directions of effect against other outcomes. Where
 d’Unienville et al. J Int Soc Sports Nutr (2021) 18:76
Table 3  Performance Level (PL) Criteria
PL1 PL2 PL3
Female V̇O2max (ml.kg.min-1) <37 37-47.9 48-53.9
Male V̇O2max (ml.kg.min-1) <45 45-54.9 55-64.9
separate populations (e.g. male vs female), performance
tests or supplementation protocols (e.g. different doses,
durations, timings) were implemented within the same
study, data were extracted as separate trials. Where
standard deviations were not reported, these were cal-
culated using standard error (SE), confidence intervals
or p values, if available, per the Cochrane Handbook for
Systematic Reviews of Interventions [37].
1.1. Synthesis of results
Where precise or upper bounds of p-values (e.g.
p<0.05) of mean differences were provided, stand-
ard error (SE) of effect size was calculated using the
equivalent T-statistic and correlation coefficients
between treatment groups were estimated in accord-
ance with Elbourne et al [38]. Where these details were
unavailable, SE was √ calculated in crossover trials as
2
SE = N1 + SMD2N × 2(1 − 0.72) , using the lowest cor-
relation coefficient of 0.72 [39]. Effects were defined
as trivial (<0.2), small (0.2–0.6), moderate (0.61–1.2),
large (1.21–2.0), and very large (>2.0) [40] and preci-
sion of the effect size estimate was assessed using 95
% confidence intervals (CIs). Separate meta-analyses
were undertaken for crossover and parallel trials.
Data from included studies were qualitatively syn-
thesised. Where suitable data were available, random
effects meta-analysis was conducted using STATA/IC
software (version 16.1, College Station, TX, StataCorp
LLC.) using the inverse variance model and restricted
maximum likelihood method. Statistical heterogene-
ity between subgroups was assessed via Cochran’s Q,
while heterogeneity within groups was evaluated by I­ 2,
with heterogeneity classified as low (­I2 < 25%), mod-
erate ­(I2 25–49%) or high (­I2 > 50%) [41, 42]. Separate
meta-analyses were conducted to investigate the effect
of study design, blinding, sex, NO precursor (e.g. poly-
phenols, ­N O3-), food source, duration of consumption
(i.e. acute vs multiple days), fitness level of study par-
ticipants, and the mode, type (i.e. time to exhaustion
vs time trial) and duration (from time trial and con-
stant load tests only) of exercise performance tests.
For subgroup analyses, fitness was classified by per-
formance level (PL) using the guidelines of De Pauw
[43] and Decroix [44] using reported running and
cycling maximal oxygen consumption (V̇O2max), as
provided in Table  3 below. Mixed-sex trials that did
Page 5 of 28
not report separate V̇O2max values for females and
PL4 PL5
males, or featured different PLs between the sexes,
were excluded from this fitness subgroup analysis. The
52-58 >58 influence of fitness was also investigated using meta-
65-71 >71 regression of outcomes against male V̇O2max values.
Results
Study selection and characteristics
A PRISMA flow diagram of the search and screening
results is displayed in Fig. 1. Of the 123 studies that were
eligible for inclusion, 103 used a crossover design and
21 used a parallel design. 101 were reported as double-
blind, 13 as single-blind, and 10 did not specify blinding.
62 studies were classified as polyphenol studies, 57 were
­NO3--focused and four studies tested L-citrulline effects,
with 40 different food sources represented. While no
included studies were specifically focused on L-arginine,
it is an additional nutritional component found in water-
melon and almonds, and studies that used these foods
were classified as L-citrulline and polyphenol studies,
respectively. Five studies did not report sufficient data to
calculate SMD, thus the meta-analysis incorporated 118
studies. Eleven studies featured multiple performance
tests, seven studies assessed the effects of various sup-
plementation durations, five studies evaluated different
supplementation dosages, three studies analysed multiple
food sources and three studies analysed multiple popula-
tions. Thus, the 118 studies with eligible data were consid-
ered as 156 separate trials (i.e. with separate effect sizes).
Data from 1872 participants, from 25 different coun-
tries were included, comprising 1482 males, 344 females
and 46 participants of unspecified sex, as sex was not
reported in four studies. From reported study means,
pooled mean age was 27.8 ± 5.9 years, with a height of
177.4 ± 10.0 cm, mass of 74.5 ± 9.9 kg and V̇O2max of
53.9 ± 6.9 ml.kg.min-1. ­NO3- trials featured a daily dose
of 8.4 ± 3.3 mmol N ­ O3-, polyphenol trials had a daily
total phenolic content of 817.4 ± 743.1 mg gallic acid
equivalents (where reported), and L-citrulline trials
reported a daily dose of 1.71 ± 1.0 g citrulline.
Risk of Bias
Risk of Bias results for each study (including specific
domain of bias scores) are provided in Additional Mate-
rial 2. Sixty-six studies had a high risk of bias, with 58
studies having ‘some concerns’ and no studies classi-
fied at low risk. Classification of high risk was most
frequently given for deviations from intended interven-
tions (53%). ‘Some concerns’ was predominant for bias
regarding selective reporting of results (100%), reporting
of missing outcome data (70%), and the randomisation
process (88%).
d’Unienville et al. J Int Soc Sports Nutr (2021) 18:76
Fig. 1  PRISMA flow diagram of search, screening and inclusion outcomes
Publication Bias
Standard and contoured funnel plots are displayed in
Figure  2. There is some asymmetry within L-citrulline
trials that is likely due to the limited number of studies,
whereas ­NO3- and polyphenol trials appeared to have
good symmetry overall and in the proportion of posi-
tive and negative non-significant effects, as assessed by
the symmetry within the dark grey shaded areas. Given
that 43 trials were designated as receiving financial sup-
port, subgroup analyses were also undertaken to help
infer whether results from privately funded studies may
have been suppressed in the absence of beneficial effects.
However, these analyses revealed no significant differ-
ences between effects of N ­ O3- studies that did or did not
receive financial support (p=0.55), whereas financially
supported polyphenol studies had significantly smaller
effects (p=0.02) than those without private funding.
Overall, these results suggest that publication bias did
not play a significant role in the meta-analysis results.
Results of syntheses
Nitrate consumption (all food sources combined)
A summary of overall and sub-group analyses is provided
in Table 4. Based on the analysis of 81 trials and 956 par-
ticipants, ­NO3- consumption provided significant, trivial
benefits for endurance exercise performance, and trials
featured low heterogeneity ­(I2=6.4%). Significant benefits
Page 6 of 28
were evident in both crossover (trivial effects) and paral-
lel (small effects) trials, but study design was not a mod-
erator of effects, and results did not differ between study
designs ­(Qb=2.37, p=0.12).
Effects by supplementation protocol  Sub-group analyses
indicated that trivial benefits existed for both acute and
multiple-day supplementation, with no significant differ-
ence between the two (p=0.08) and no significant influ-
ence of the number of supplementation days (p=0.12).
Meta-regression indicated that daily N ­ O3-dosage of inter-
ventions was not associated with performance effects
overall (p=0.93), or within acute (p=0.62) and multiple-
day (p=0.49) supplementation trials specifically. Sixteen
­ O3- sources, but
trials restricted intake of other dietary N
effects within this subgroup were no different from trials
without restrictions ­(Qb=0.55, p=0.46).
Sex and fitness‑specific effects  Effects differed by classifi-
cation of participant sex (­Qb=6.94, p=0.03), as trivial ben-
efits were still seen in male-only and mixed-sex studies, but
females demonstrated no effects (SMD=0.0, p=0.98) from
the results of only four trials. Effects differed by PL over-
all ­(Qb = 8.78, p=0.03), but when trials were restricted to
males only these differences were not significant (­ Qb = 6.39,
p=0.09) and meta-regression indicated that V̇O2max was
not a significant mediator of the size of performance effects
 d’Unienville et al. J Int Soc Sports Nutr (2021) 18:76 Page 7 of 28

Fig. 2  Standard and contoured funnel plots of nitrate, polyphenol, and L-citrulline effects
d’Unienville et al. J Int Soc Sports Nutr (2021) 18:76 Page 8 of 28

Table 4  Nitrate meta-analysis and sub-group analyses

k n SMD (95% CIs) p I2 (%)

Overall 81 956 0.15 [0.12, 0.18] <0.001 6.4

Design Qb: 2.37 0.121
Crossover 76 856 0.14 [0.11, 0.17] <0.001 0
Parallel 5 100 0.36 [0.08, 0.64] 0.011 32
Blinding Qb: 1.29 0.544
Single blind 8 77 0.11 [-0.002, 0.22] 0.054 0
Double blind 71 857 0.16 [0.12, 0.19] <0.001 0
Unclear 2 22 0.07 [-0.14, 0.29] 0.519 60
Supplementation dura‑ Qb: 3.05 0.084
tion
Acute 38 437 0.12 [0.06, 0.17] <0.001 13
Multiple days 43 519 0.18 [0.13, 0.22] <0.001 9
Sex1 Qb: 6.94 0.031
Male 59 658 0.16 [0.12, 0.20] <0.001 0
Female 4 48 0.0 [-0.12, 0.11] 0.988 0
Mixed 16 229 0.15 [0.09, 0.21] <0.001 0
Performance level Qb: 8.78 0.032
PL12 1 14 -0.29 [-0.69, 0.11] 0.156 -
PL2 23 290 0.24 [0.12, 0.35] <0.001 52
PL2 females -
PL2 males: 17 181 0.24 [0.11, 0.36] <0.001 52
GXT 3 34 0.16 [-0.14, 0.46] 0.300 80
IGXT 1 14 0.22 [0.01, 0.44] 0.040
ITTE 1 12 0.47 [0.03, 0.91] 0.038
TT 4 47 0.01 [-0.28, 0.29] 0.975 53
TTE 8 74 0.39 [0.21, 0.57] <0.001 27
PL3 15 154 0.18 [0.12, 0.24] <0.001 0
PL3 females -
PL3 males: 15 154 0.18 [0.12, 0.24] <0.001 0
GXT 2 17 0.1 [-0.27, 0.47] 0.612 53
ITT 2 20 0.17 [0, 0.35] 0.592 0
TT 8 82 0.17 [0.1, 0.24] <0.001 0
TTE 3 35 0.26 [-0.18, 0.69] 0.249 71
PL4 8 87 0.03 [-0.14, 0.2] 0.762 0
PL4 females 1 14 0.02 [-0.37, 0.42] 0.912 -
PL4 males: 7 73 0.03 [-0.16, 0.22] 0.787 0
GXT 1 12 2.17 [-1.8, 6.14] 0.289 -
TT 6 61 0.02 [-0.17, 0.22] 0.825 0
PL5 6 57 -0.02 [-0.22, 0.17] 0.821 0
PL5 females 1 12 -0.01 [-0.43, 0.42] 0.980 -
PL5 males: 5 45 -0.03 [-0.25, 0.19] 0.808 0
ITTE 1 9 -0.07 [-0.56, 0.42] 0.801 -
TT 4 36 -0.02 [-0.27, 0.23] 0.882 0
Exercise mode Qb: 2.29 0.825
Cycling 53 625 0.17 [0.12, 0.22] <0.001 22
Hand cycling 4 39 0.02 [-0.21, 0.26] 0.859 0
Incline walk/run 1 14 -0.29 [-0.69, 0.11] 0.156 -
Kayaking 2 14 0.13 [-0.02, 0.28] 0.093 0
Rowing 2 20 0.09 [-0.24, 0.42] 0.604 0
Running 15 196 0.14 [0.07, 0.21] <0.001 19
 d’Unienville et al. J Int Soc Sports Nutr (2021) 18:76 Page 9 of 28

Table 4  (continued)
k n SMD (95% CIs) p I2 (%)

Swimming 4 48 0.12 [0.004, 0.23] 0.042 0

Test type Qb: 10.29 0.059
GXT 15 176 0.15 [0.02, 0.27] 0.023 59
IGXT 2 50 0.13 [0.03, 0.22] 0.008 0
ITT 4 44 0.13 [0.002, 0.27] 0.046 0
ITTE 2 21 0.21 [-0.02, 0.39] 0.244 60
TT 39 436 0.12 [0.07, 0.16] <0.001 0
TTE 19 229 0.31 [0.20, 0.42] <0.001 29
Test duration Qb: 2.89 0.577
<5 mins: 11 104 0.16 [0.08, 0.23] <0.001 0
TT 8 70 0.12 [0.04, 0.21] 0.005 0
TTE 3 34 0.32 [0.07, 0.56] 0.011 29
5-10 mins: 24 276 0.18 [0.09, 0.27] <0.001 31
TT 11 112 0.12 [0.02, 0.22] 0.016 7
TTE 13 164 0.29 [0.13, 0.44] <0.001 40
10-30 mins: 12 122 0.16 [0.04, 0.28] 0.007 41
TT 9 91 0.12 [-0.004, 0.23] 0.058 41
TTE 3 31 0.44 [0.16, 0.73] 0.002 0
30-60 mins: 5 60 0.08 [-0.11, 0.28] 0.397 0
TT 5 60 0.08 [-0.11, 0.28] 0.397 0
>60 mins: 4 51 0.00 [-0.21, 0.21] 0.986 0
TT 4 51 0.00 [-0.21, 0.21] 0.986 0
Overall (TT & TTE) 56 613 0.15 [0.11, 0.19] <0.001 2
1
Sex not specified in two trials. Abbreviations – GXT, graded exercise test; IGXT, intermittent graded exercise test; ITT, intermittent time-trial; ITTE, intermittent time
to exhaustion; k, number of trials; LCI, lower confidence interval; n, pooled sample size; PL, performance level; Q
­ b, between-group Q-statistic; SMD, standardised mean
difference (Hedge’s g); TT, time-trial; TTE, time to exhaustion; UCI, upper confidence interval

(p=0.10). Most trials included participants classified as PL2,
who demonstrated small, significant benefits. Male PL2
(V̇O2max: 45-55 ml.kg.min-1) trials exhibited a small, signifi-
cant improvement overall and within TTE trials specifically,
but showed no change in TT performance and insignificant
trivial benefits for GXT performance. Within the male PL3
bracket (V̇O2max: 55-65 ml.kg-1.min-1), a significant trivial
improvement was seen for overall performance, which was
still evident for TT performance, while small but insignifi-
cant improvements were observed for TTE performance
and trivial insignificant effects were indicated for GXT
and ITT trials. No effect was present for males in the PL4
(V̇O2max: 65-71 ml.kg-1.min-1) or PL5 brackets (V̇O2max >71
ml.kg-1.min-1) which were evaluated predominantly through
TT performance. Female PL subgroup analyses were not
conducted as data were unavailable from female PL2 or PL3
trials and other PLs only included a single study.
Effects by test type and duration  Although effects
did not vary between performance test subgroups
­(Qb=10.63, p=0.059), non-significant trivial effects
were evident for intermittent time trial (ITT) tests,
while significant trivial effects were identified for
intermittent graded exercise tests (IGXT), time trials
(TT) and graded exercise tests (GXT). Small, signifi-
cant improvements were found in time to exhaustion
(TTE) tests, whereas small non-significant benefits were
observed for intermittent time to exhaustion (ITTE)
tests. There was no heterogeneity within IGXT, ITT
or TT trials (­I2=0%), but moderate heterogeneity was
present in TTE ­(I2=29%) trials and high heterogene-
ity was present for GXT ­(I2=47%) and ITTE ­(I2=60%)
trials. Effect sizes within various test duration brackets
during TTs and TTE tests are provided in Table 4, and
meta-regression found no influence of test duration on
performance outcomes for TTs (p = 0.52) or TTE tests
(p = 0.48). Since PL2 and PL3 for males were the only
categories that demonstrated significant benefits over-
all, meta-regression was also performed for this sub-
group specifically, which found no influence of duration
on effects within TTs (p = 0.76) or TTE tests (p = 0.64).
Effects of different nitrate food sources
Sub-group analysis indicated that consumption of
­(NO3--rich) beetroot demonstrated a significant, trivial
d’Unienville et al. J Int Soc Sports Nutr (2021) 18:76
improvement in exercise performance (Fig.  3), with
studies predominantly using beetroot juice as the deliv-
ery method (Additional Material 3). No significant
effects were evident for consumption of red spinach
or Swiss chard and rhubarb from a limited number of
studies, but between-food effects were not statisti-
cally different between food sources of ­NO3- ­(Qb=1.03,
p=0.60).
Polyphenol supplementation effects
The analysis of polyphenol effects included 71 trials and
1227 participants, indicating significant, trivial ben-
efits for consumption of polyphenol-rich foods overall
(Table  4), with these effects influenced by high hetero-
geneity ­(I2 = 66%). Forty-five (of 71) trials quantified
the polyphenol content of the foods consumed, but the
overall effects of these trials were not different from tri-
als where polyphenol content was unspecified, and total
phenolic content of the foods consumed did not influ-
ence effects (p=0.27). There were few differences in sub-
group effects (parallel, GXT, TTE, PL1, PL2, and acute
trials) in comparison to all polyphenol studies combined
(Table 5), and given the similarities between studies that
did and did not report polyphenol content, the results
presented in-text represent all polyphenol trials. Crosso-
ver trials produced trivial, significant benefits, whereas
small, insignificant improvements were shown in parallel
trials, although subgroup analyses indicated that results
between parallel and crossover trials were not signifi-
cantly different (p=0.55).
Effects by supplementation protocol  Small, significant
benefits were evident for acute supplementation and
trivial, significant improvements were exhibited after
multiple-day consumption, with high heterogeneity for
both acute and multiple-day supplementation. Effects did
not differ between acute and multiple-day supplementa-
tion (p=0.07), nor did the number of supplementation
days appear to be a significant moderator of outcomes
(p=0.47). Twenty-eight of 56 multiple-day studies pro-
vided an acute dose before testing, but effects were not
different from multiple-day polyphenol trials that did
not include a pre-testing dose (p=0.37). Seventeen tri-
als restricted intake of foods rich in antioxidants and/
or polyphenols, and subgroup analyses indicated no
(See figure on next page.)
Fig. 3  Nitrate supplementation forest plot. Abbreviations – %Δ, work rate that would achieve x% of difference between V̇O2 at gas exchange
threshold and V̇O2peak; CI, confidence interval; GXT, graded exercise test; IGXT, intermittent graded exercise test; ITT, intermittent time-trial; ITTE,
intermittent time to exhaustion; k, number of trials; km, kilometre; n, sample size; N­ O3-, nitrate; PL, performance level; ­Qb, between-group Q-statistic;
rpm, revolutions per minute; s, second; SMD, standardised mean difference (Hedge’s g); supp., supplementation; TT, time-trial; TTE, time to
exhaustion.
Page 10 of 28
between-group differences with polyphenol trials that
had no restrictions ­(Qb=0.74, p=0.39).
Effects by sex and fitness  Small, significant benefits
were identified for studies with males only, with no
effect in female or mixed-sex studies. Small, signifi-
cant improvements were evident in males in the PL2,
PL3 and PL4 brackets, with no eligible studies for PL5,
and V̇O2max did not mediate performance effect sizes
(p=0.76). Low heterogeneity (­I2=0%) was evident for
the male PL2 and PL4 brackets, while moderate het-
erogeneity ­(I2= 48%) was evident for male PL3 trials.
Two female PL3 (V̇O2max: 48-52 ml.kg-1.min-1) trials
indicated no effects, with no other female trials avail-
able to classify by PL.
Effects by duration and test type  Significant, trivial
improvements were found for TT and TTE performance,
and significant moderate improvements were evident
for IGXT, with no significant effects for other test types.
One IGXT study [100] likely included a reporting error
(very low SD), but even with this trial removed, the effect
within IGXTs remained moderate. No significant effects
were identified for performance tests with durations or
<5 minutes or 5-10 minutes, while trivial, significant ben-
efits were seen in tests lasting 10-30 minutes and 30-60
minutes. Small, but significant performance decrements
were seen in performance (all TT) with a duration of >60
minutes. Meta-regression did not indicate a significant
influence of exercise duration within TTs (p=0.49) or
TTE tests (p=0.40).
Polyphenol‑rich foods
Trials evaluating effects of polyphenol-rich foods
evaluated 36 separate food sources. Effects on exer-
cise performance are displayed in Fig.  4, with sig-
nificant differences between food sources ­(Qb=32.64,
p=0.002). Moderate, significant benefits were exhibited
for the consumption of grape (juice), small significant
improvements were seen following consumption of
French maritime pine bark extract and Montmorency
cherry, and significant, trivial benefits were demon-
strated for ­N O3--depleted beetroot and pomegranate.
 d’Unienville et al. J Int Soc Sports Nutr (2021) 18:76 Page 11 of 28

Fig. 3  (See legend on previous page.)

Table 5  Polyphenol meta-analysis and sub-group analyses
All polyphenol trials Trials with polyphenols quantified
k n SMD (95% CIs) p I2 (%) k n SMD (95% CIs) p I2 (%)

Overall 71 1227 0.17 [0.10, 0.25] <0.001 66 45 829 0.20 [0.09, 0.30] <0.001 72
Design Qb: 0.04 0.548 Qb: 3.53 0.060
Crossover 52 730 0.16 [0.08, 0.23] <0.001 65 34 481 0.14 [0.04, 0.24] 0.006 66
Parallel 19 497 0.24 [-0.02, 0.49] 0.069 56 12 348 0.47 [0.14, 0.81] 0.006 59
d’Unienville et al. J Int Soc Sports Nutr

Blinding Qb: 0.34 0.845 Qb: 0.13 0.714

Single blind 6 122 0.30 [-0.3, 0.91] 0.329 91 6 122 0.30 [-0.30, 0.91] 0.329 91
Double blind 58 987 0.17 [0.10, 0.24] <0.001 51 38 674 0.19 [0.08, 0.29] <0.001 67
Unclear 7 118 0.10 [-0.27, 0.46] 0.621 76 1 33 -0.18 [-0.8, 0.44] 0.572 -
Supplementation Qb: 0.12 0.733 Qb: 1.46 0.228
(2021) 18:76

duration
Acute 15 243 0.21 [0.003, 0.41] 0.046 85 5 101 0.56 [-0.07, 1.19] 0.081 95
Multiple days 56 984 0.17 [0.09, 0.25] <0.001 57 40 728 0.17 [0.07, 0.27] 0.001 61
Polyphenol quanti‑ Qb: 1.13 0.287
fication
No 26 398 0.14 [0.04, 0.25] 0.009 52
Yes 45 829 0.2 [0.09, 0.30] <0.001 72
1
Sex Qb: 7.49 0.024 Qb: 0.31 0.210
Male 45 729 0.23 [0.15, 0.32] <0.001 42 31 556 0.20 [0.08, 0.32] <0.001 46
Female 4 71 0.01 [-0.19, 0.20] 0.948 0 3 55 0.01 [-0.19, 0.21] 0.942 0
Mixed 19 388 0.05 [-0.09, 0.19] 0.460 78 8 179 0.26 [-0.05, 0.57] 0.098 94
Performance level Qb: 12.90 0.005 Qb: 1.17 0.558
PL1 3 89 0.76 [0.37, 1.15] <0.001 0 2 80 0.59 [-0.08, 1.25] 0.083 0
PL1 Females - -
PL1 Males: 3 89 0.76 [0.37, 1.15] <0.001 0 2 80 0.59 [-0.08, 1.25] 0.083 0
GXT 2 80 0.59 [-0.08, 1.25] 0.083 0 2 80 0.59 [-0.08, 1.25] 0.083 0
TT 1 9 0.86 [0.38, 1.34] <0.001 - -
PL2 19 279 0.12 [0, 0.25] 0.059 36 14 207 0.21 [0.09, 0.34] <0.001 0
PL2 Females - -
PL2 Males: 17 239 0.21 [0.11, 0.32] <0.001 0 14 207 0.21 [0.09, 0.34] <0.001 0
GXT 6 94 0.23 [-0.02, 0.47] 0.068 16 6 94 0.23 [-0.02, 0.47] 0.068 16
IGXT 1 26 2.54 [0.13, 4.96] 0.039 - 1 26 2.54 [0.13, 4.96] 0.039 -
ITTE 1 13 0.26 [-0.18, 0.7] 0.252 - 1 13 0.26 [-0.18, 0.7] 0.252 -
Page 12 of 28
Table 5  (continued)
All polyphenol trials Trials with polyphenols quantified
k n SMD (95% CIs) p I2 (%) k n SMD (95% CIs) p I2 (%)

TT 6 64 0.18 [0.01, 0.35] 0.042 0 5 54 0.21 [0.02, 0.39] 0.028 0

TTE 3 42 0.21 [0.03, 0.4] 0.021 0 1 20 0.12 [-0.21, 0.45] 0.492 -
PL3 18 275 0.22 [0.08, 0.36] 0.002 31 13 219 0.22 [0.06, 0.34] 0.002 36
PL3 Females 2 44 0.05 [-0.17, 0.28] 0.646 0 2 44 0.05 [-0.17, 0.28] 0.646 0
PL3 Males: 16 231 0.28 [0.14, 0.42] <0.001 36 11 175 0.28 [0.08, 0.49] 0.006 39
d’Unienville et al. J Int Soc Sports Nutr

IGXT 1 13 0.54 [0.1, 0.97] 0.016 - 1 13 0.54 [0.1, 0.97] 0.016 -

TT 11 177 0.24 [0.08, 0.41] 0.004 59 9 152 0.24 [0.03, 0.46] 0.029 42
TTE 4 57 0.35 [-0.01, 0.71] 0.056 20 1 10 1.1 [-1.02, 3.22] 0.314 -
PL4 2 19 0.49 [0.21, 0.77] <0.001 0 1 9 0.41 [0.08, 0.75] 0.015 -
(2021) 18:76

PL4 Females - -
PL4 Males: 2 19 0.49 [0.21, 0.77] <0.001 0 1 9 0.41 [0.08, 0.75] 0.015 -
TT 2 19 0.49 [0.21, 0.77] <0.001 0 1 9 0.41 [0.08, 0.75] 0.015 -
PL5 - -
Exercise mode Qb: 6.32 0.097 Qb: 10.15 0.006
Cycling 39 589 0.15 [0.06, 0.24] 0.001 54 27 431 0.14 [0.04, 0.23] 0.004 40
Incline Walk/Run 4 83 0.54 [0.21, 0.87] 0.001 0 2 60 0.63 [0.02, 1.24] 0.043 0
Rowing 2 37 -0.32 [-1.34, 0.71] 0.556 63 1 19 -0.84 [-1.74, 0.05] 0.064 -
Running 24 489 0.22 [0.10, 0.33] <0.001 62 13 290 0.44 [0.17, 0.71] 0.001 82
Swimming 1 11 -0.18 [-0.63, 0.27] 0.434 - 1 11 -0.18 [-0.18, 0.27] 0.112 -
Climbing 1 18 -0.62 [-1.0, -0.25] 0.001 - 1 18 -0.62 [-1.0, -0.25] 0.001 -
Test type Qb: 10.29 0.016 Qb: 11.46 0.009
GXT 17 352 0.14 [-0.001, 0.28] 0.052 23 11 249 0.22 [0.04, 0.39] 0.016 37
IGXT 4 73 1.09 [0.50, 1.68] <0.001 66 4 73 1.09 [0.50, 1.68] <0.001 66
ITTE 1 13 0.26 [-0.18, 0.70] 0.252 - 1 13 0.26 [-0.18, 0.70] 0.252 -
TT 35 549 0.12 [0.03, 0.21] 0.011 59 24 370 0.10 [0.01, 0.20] 0.037 41
TTE 14 240 0.16 [0.01, 0.31] 0.037 63 5 124 0.17 [-0.39, 0.72] 0.563 88
Test duration Qb: 2.40 0.663 Qb: 5.57 0.135
<5 mins: 4 49 0.26 [-0.08, 0.59] 0.133 91 1 12 -0.08 [-0.21, 0.06] 0.257 -
Page 13 of 28
Table 5  (continued)
All polyphenol trials Trials with polyphenols quantified
d’Unienville et al. J Int Soc Sports Nutr

k n SMD (95% CIs) p I2 (%) k n SMD (95% CIs) p I2 (%)

TT 2 21 0.36 [-0.55, 1.27] 0.446 93 1 12 -0.08 [-0.21, 0.06] 0.257 -

TTE 2 28 0.20 [0.07, 0.33] 0.002 0 -
5-10 mins: 9 124 0.08 [-0.14, 0.30] 0.472 73 4 56 -0.11 [-0.43, 0.22] 0.532 76
(2021) 18:76

TT 3 36 -0.01 [-0.16, 0.14] 0.873 0 2 18 -0.02 [-0.17, 0.13] 0.807 0

TTE 6 88 0.11 [-0.23, 0.45] 0.532 80 2 38 -0.25 [-0.97, 0.48] 0.516 88
10-30 mins: 19 339 0.19 [0.12, 0.26] <0.001 0 12 234 0.22 [0.1, 0.33] <0.001 14
TT 16 264 0.21 [0.1, 0.32] <0.001 27 10 176 0.21 [0.06, 0.36] 0.006 35
TTE 3 75 0.18 [0.02, 0.34] 0.031 0 2 58 0.21 [0.03, 0.4] 0.024 0
30-60 mins: 9 122 0.12 [0.03, 0.21] 0.008 0 6 77 0.11 [0.01, 0.2] 0.036 0
TT 7 101 0.12 [0.03, 0.21] 0.008 0 6 77 0.11 [0.01, 0.2] 0.036 0
TTE 2 21 0.04 [-0.32, 0.41] 0.828 19 -
>60 mins: 5 104 0.14 [-0.38, 0.66] 0.608 83 3 64 0.52 [-0.2, 1.4] 0.206 71
TT 4 76 -0.08 [-0.46, 0.29] 0.673 65 2 36 0.33 [-0.61, 1.27] 0.506 75
TTE 1 28 0.97 [0.21, 1.73] 0.013 - 1 28 0.97 [0.21, 1.73] 0.013 -
Overall (TT & TTE) 46 738 0.14 [0.06, 0.21] <0.001 59 26 443 0.11 [0.01, 0.21] 0.038 61
1
Sex not specified in three trials. Abbreviations – GXT, graded exercise test; IGXT, intermittent graded exercise test; ITTE, intermittent time to exhaustion; k, number of trials; LCI, lower confidence interval; n, pooled
sample size; PL, performance level; Qb, between-group Q-statistic; SMD, standardised mean difference (Hedge’s g); TT, time-trial; TTE, time to exhaustion; UCI, upper confidence interval
Page 14 of 28
 d’Unienville et al. J Int Soc Sports Nutr (2021) 18:76 Page 15 of 28

Fig. 4  Polyphenol supplementation forest plot. Abbreviations – CI, confidence interval; GXT, graded exercise test; IGXT, intermittent graded
exercise test; ITTE, intermittent time to exhaustion; k, number of trials; n, sample size; PL, performance level; Qb, between-group Q-statistic; SMD,
standardised mean difference (Hedge’s g); supp., supplementation; TT, time-trial; TTE, time to exhaustion; ­Vmax, maximal running velocity.
d’Unienville et al. J Int Soc Sports Nutr (2021) 18:76 Page 16 of 28

Fig. 4 continued

Small effects were found for the consumption of cocoa/ blueberry, green tea, New Zealand blackcurrant, pea-
chocolate, but this did not reach statistical signifi- nut and mango leaf, or raisins, while a significant,
cance (p=0.052). No effects (SMD<0.1) were evident trivial performance decrement was evident following
for the consumption of American or Siberian ginseng, banana consumption. Two Panax ginseng studies [101,
 d’Unienville et al. J Int Soc Sports Nutr (2021) 18:76
Fig. 5  L-citrulline supplementation forest plot. Abbreviations – n, sample size; SMD, standardised mean difference (Hedge’s g); CI, confidence
interval; GXT, graded exercise test; IGXT, TT, time-trial; TTE, time to exhaustion; Q
102] and one study investigating the effects of honey
consumption [103] did not provide sufficient infor-
mation for inclusion in the meta-analysis, and each of
these studies failed to demonstrate significant effects
on exercise performance.
L‑citrulline/Watermelon juice supplementation
L-citrulline (consumed via watermelon juice in all stud-
ies) had insignificant trivial detrimental effects on
exercise performance based on the results of 4 trials
(Figure 5). As shown in Additional Material 4, no signifi-
cant effects were evident for any subgroup analysis (e.g.
exercise mode, type, V̇O2max etc.) and all included studies
featured low statistical heterogeneity ­(I2= 0%). An addi-
tional study by Tarazona-Diaz et al. [161] not included in
the meta-analysis due to insufficient data reporting also
failed to demonstrate any effect of watermelon juice on
exercise performance.
Discussion
Key findings
Consumption of foods rich in N ­ O3- and polyphenols
exhibited trivial beneficial effects on endurance exercise
performance, while no effects of consuming foods rich
in L-citrulline were apparent. Grapes, French maritime
pine bark and Montmorency cherry, were the most effec-
tive food sources of polyphenols, and males may benefit
further from polyphenol consumption, with small per-
formance improvements (including small and moder-
ate effects in TT and IGXT performance, respectively).
Females do not appear to benefit from consumption of
­NO3-or polyphenols, although there are sample size limi-
tations. Fitness does not appear to influence the response
to polyphenol consumption, while less-trained male ath-
letes (V̇O2max: 45-55 ml.kg.min-1) may obtain the greatest
benefits from ­NO3- consumption and no effects of ­NO3-
are seen in more highly trained athletes (V̇O2max: >65
ml.kg.min-1).
Page 17 of 28
­ b, between-group Q-statistic.
Nitrate
Findings and proposed mechanisms
This meta-analysis provided evidence that consumption
of dietary ­NO3-, particularly via consumption of beet-
root, provided trivial but significant benefits for endur-
ance exercise performance. This finding corresponds
with other reviews that have investigated the ergogenic
potential of N ­ O3-, despite some differences in eligible
performance measures (e.g. minimum performance dura-
tion, inclusion of non-locomotor performance) and the
inclusion of non-food-derived sources such as sodium
and potassium ­NO3- [165, 166]. Within this review, ­NO3-
consumption displayed significant, small benefits for
TTE performance and trivial benefits for TT, GXT per-
formance, with effect sizes aligned with those of McMa-
hon et  al. [165]. This review also assessed the effects of
­NO3- on intermittent performance tests, which are more
relevant for team-sport athletes given the intermittent
nature of their competition, and trivial benefits were
found for ITT and IGXT performance. Consistent with
Campos et  al. [165], we found that effects of N ­ O3- on
exercise performance are reduced in more highly condi-
tioned athletes. Sub-group analyses indicated that while
no effects were evident for athletes with higher V̇O2max
values (>65 ml.kg.min-1), there were significant small and
trivial benefits from N­ O3- consumption in males with a
V̇O2max of 45-55 and 55-65 ml.kg.min-1, respectively.
Overall, these results suggest that beetroot juice may
confer the greatest benefit in males of lower fitness, par-
ticularly during TTE tests. The improvements in exer-
cise performance may have resulted from increases in
nitric oxide synthesis and vascular function, as inferred
via elevated levels of N ­ O3-and nitrite, and reductions
in systolic blood pressure (Additional Material 3),
which enhance oxygen delivery and exercise efficiency
[8]. These exercise effects were most apparent in less-
trained individuals, who demonstrated more frequent
reductions in submaximal oxygen consumption and
d’Unienville et al. J Int Soc Sports Nutr (2021) 18:76
augmentation of tissue oxygenation and oxygen uptake
kinetics following ­ NO3- supplementation (Additional
Material 3). Improvements in exercise performance
with ­NO3- intake are believed to be a result of improved
mechanical efficiency and V̇O2 kinetics that derive from
effects on fast-twitch muscle fibres [8], such as enhance-
ment of excitation-contraction coupling. However, the
reduced percentage of fast-twitch fibres and increased
expression of calcium handling proteins [167] in elite
endurance athletes, may limit these effects, in addition
to their increased levels of endogenous nitric oxide syn-
thesis [168, 169], vascular function [26, 29] and habitual
dietary ­NO3- intake [170].
Food‑specific effects of nitrate consumption
While beetroot juice was the predominant food source
of ­NO3- in the included trials, which demonstrated triv-
ial benefits for performance, a small number of studies
evaluated the effect of ­NO3- from other sources, such as
red spinach [97, 98], Swiss chard and rhubarb [99]. These
studies reported no benefit for exercise performance;
however this may be due to the lower N ­ O3- content (~1.5
mmol vs average of 8.4 mmol within included studies)
[97, 98] and the assessment of time-trial performance in
trained (PL2) males, for which ­NO3- consumption overall
demonstrated no benefit [99].
Notably, the included ­(NO3--rich) beetroot studies pre-
dominantly used N ­ O3--depleted beetroot juice as the
comparator, and these studies are therefore assessing the
effects of their high N­ O3- content, rather than their over-
all nutritional properties. Beetroot juice, including com-
mercial concentrated shots (e.g. James White Drinks Ltd,
Ipswich, UK) typically used in studies, possesses high total
phenolic content and antioxidant activity [171–173], which
may confer additional advantages for exercise performance.
Lansley et al. [72] found no significant effects of consum-
ing ­NO3--depleted beetroot juice, suggesting that ergogenic
effects of beetroot juice are attributable to its ­NO3- content,
yet within this review, ­ NO3--depleted beetroot supple-
mentation exhibited trivial but significant benefits for per-
formance [72, 109–111]. Thus, the full effects of beetroot
may be somewhat underestimated in studies that have used
­NO3--depleted beetroot juice as a comparator.
Polyphenols
Findings and proposed mechanism
The current analysis identified that consumption of
polyphenol-rich foods, both acutely and over several
days, resulted in trivial but significant effects on endur-
ance exercise performance. This is in agreement with
a previous polyphenol meta-analysis [174], although
Page 18 of 28
their included interventions included purified poly-
phenol extracts from unspecified food sources in addi-
tion to whole-food extracts. Responses between and
within foods varied significantly in the present analy-
sis, as demonstrated by high heterogeneity, which may
reflect the complex interplay between the food matrix,
its phytochemical and nutritional composition, back-
ground diet and other genetic factors that have been
shown to produce significant inter-individual variation
in the responses to polyphenol consumption [19, 20].
This variation in the response between different foods
is typified by both the non-significant influence of total
phenolic content on effect size, as well the differential
effects between food sources with similar predominant
polyphenolic compounds (e.g. anthocyanins in blueber-
ries, cherries and blackcurrant), as can be seen in Table 6
and the phenolic content of interventions listed in Addi-
tional Material 3. Further differences in interventions of
included studies such as the consumption of single vs
multiple polyphenol-rich food sources, the use of whole
foods, juices, powders or extracts, as well as restrictions
on specific foods or antioxidant sources, may contribute
to such heterogeneous responses. Grape, (­ NO3--depleted)
beetroot, French maritime pine, pomegranate and Mont-
morency cherry were the only polyphenol-rich foods that
demonstrated significant ergogenic effects, while foods
sources such as carob, Danggui Buxue Tang, Ecklonia
cava, Rhodiola rosea, Spirulina platensis and yerba mate
have shown promising effects within single studies and
warrant further investigation.
The potential benefits of polyphenols for exercise per-
formance are frequently attributed to their proposed
ability to enhance vascular function and limit oxidative
damage during exercise by upregulating endogenous
antioxidant capacity. However, direct evidence of the
physiological mechanisms underpinning the perfor-
mance changes observed within the included studies
was limited. As shown in Additional Material 3, only five
polyphenol studies included a direct measure of nitric
oxide status (e.g. plasma ­NO3- or ­NO2-), with only one
study [149] demonstrating a significant increase in any
of these biomarkers (plasma N ­ O3-) following polyphenol
(pomegranate) consumption. Similarly, only 14 polyphe-
nol studies investigated effects on vascular parameters
such as flow-mediated dilation (FMD) and blood pres-
sure. Improvements in resting FMD were only observed
following consumption of cocoa [119] and a cranberry
and grape seed extract [122] in well-trained and elite ath-
letes, respectively, while two studies found post-exercise
(30-90 minutes) improvements in blood flow [151], and
systolic blood pressure [138]. Food-derived polyphenol
consumption has had inconsistent effects on vascular
 d’Unienville et al. J Int Soc Sports Nutr (2021) 18:76
Table 6  Key polyphenols found in review food sources
Group Subclasses
Flavonoids Anthocyanidins
Flavanols (Flavan-3-ol)
Flavanones
Flavones
Flavonols
Phenolic acids Benzoic acid derivatives
Cinnamic acid derivatives
Stilbenes Stillbenoids
Tannins Hyrdolysable tannins
Condensed tannins (Proanthocyanidins)
Phlorotannins
function in other healthy populations overall, although
consumption of specific polyphenol sources such as tea,
cocoa/chocolate and soy has demonstrated more con-
sistent improvements in FMD [191, 192], and thus vas-
cular effects may also be food-specific. However, vascular
and skeletal muscle neuronal and endothelial NOS are
upregulated by chronic exercise [3], fitness is signifi-
cantly correlated with nitric oxide production [26, 168]
and athletes may also have greater NO bioavailability via
enhanced antioxidant defences, all of which may limit
the vascular benefits seen in other populations. There
was also little evidence for other mechanisms of action,
such as improvements in markers of oxidative stress and
muscle damage, or internal performance parameters
(e.g. oxygen consumption, blood lactate accumulation).
Thus, the mechanisms by which polyphenol-rich foods
improve endurance exercise performance requires fur-
ther consideration.
­ O 3-
Influence of fitness  While the positive effects of N
consumption appeared to decrease with greater levels
of aerobic fitness, such a relationship was not appar-
ent in polyphenol trials, as small benefits were evident
across a range of fitness levels (PL1, PL3 and PL4).
When restricted to males only, small, significant ben-
efits were shown in PL2 trials. Of considerable inter-
est is that within males, small effects remained for TT
performance within each PL3 & PL4 (only one TT
trial in PL1). A 2017 meta-analysis of the performance
effects of polyphenols, though not restricted to food
sources, also reported that training status did not affect
response to supplementation, with polyphenols having
Page 19 of 28
Food sources Example compounds
Berries, cherries, blackcurrants, grapes Cyanidin
[15]
Green tea, cocoa, [15] Catechin
Citrus, cherries [15] Hesperidin
Beetroot, fruit skins, Thai ginseng [15, Luteolin
175]
Apples, beetroot, cherries, nuts, olive oil, Quercetin
cranberries [15]
Beetroot, nuts, cranberries, ginger, Gallic acid
chokeberry [15], Yerba mate [176], Vanillic acid
ginseng [177–179], cranberries, banana p-coumaric acid
[180], Aloe arborescens [181], Danggui Caffeic acid
Buxue Tang [182], honey [183], Spirulina Chlorogenic acid
[184], Protandim [185, 186]
Grapes, nuts [15] Resveratrol
Pomegranate, blackcurrant, French mari- Ellagitannins
time bark [187], Carob [188], Ecklonia Procyanidin
cava [189], Rhodiola rosea [190] Dieckol
­ O 3-
a significant ergogenic effect overall [174]. Unlike N
trials, no data were available for PL5 athletes within this
review, although several studies have been conducted
on high-level endurance athletes where V̇O2max data
was unavailable, or a PL was not allocated due to test
modality differences. No effects were seen following
polyphenol supplementation in national-level rowers
[105, 112], a cohort of elite athletes (primarily speed-
skaters) [122], or national-level runners [147], although
the latter two studies [122, 147] utilised a performance
test mode that was not specific to their discipline. Given
the lack of polyphenol studies evaluating the responses
of elite endurance athletes, the efficacy of polyphenol
consumption for this population remains unclear and
warrants further investigation.
Influence of polyphenol consumption protocol (dosage &
supplementation duration)  Several sub-group analy-
ses were used to investigate the possible influences of
dose and duration of consumption on the response to
polyphenol-rich foods. Regression analysis indicated
that total phenolic content was not a significant mod-
erator of effects, suggesting a lack of a dose-response
relationship between polyphenol intake and endurance
exercise performance. Further, two included studies
provided separate effect sizes for responses to differ-
ing levels of polyphenol content of the same food, and
while these studies indicated no dose-response rela-
tionship, neither study induced a significant effect in
response to any dosage [108, 148]. There were also no
significant differences in the effects between acute and
multiple-day consumption, suggesting no influence of
d’Unienville et al. J Int Soc Sports Nutr (2021) 18:76
duration of consumption. Three studies investigated
the responses to polyphenol consumption across differ-
ent supplementation periods but showed no effect for
any supplementation length [113, 148, 156]. Also, while
some multiple-day N ­ O3- loading protocols included an
additional acute dose approximately 2.5 hours before
exercise performance testing, only half of the multiple-
day polyphenol trials reported the use of an acute dose
(see Additional Material 3). Pharmacokinetic analyses
have indicated that plasma polyphenol concentrations
typically peak around 2.2 hours post-ingestion [193], yet
effects between multiple-day polyphenol trials that did
or did not include an additional acute dose before per-
formance testing were equivocal. Given the unclear role
of food total phenolic content, variation in pre-exercise
consumption timing and similar results between acute
and multiple-day supplementation, these results do not
provide clear insights into recommendations for con-
sumption protocols that can optimise the ergogenic
response to polyphenol-rich foods.
L‑Citrulline/Watermelon Juice
Four watermelon juice studies were included within the
review, which were conducted in participants of multi-
ple fitness levels (two trials each for PL2 and PL3) and
assessed performance through GXTs, ITTs, TTs and
TTE tests. However, the included studies had significant
differences in the l-citrulline content of the watermelon
juice used. Bailey et  al. [162] used concentrated water-
melon juice containing 2.3-3.4 times the l-citrulline
content in the pureed juice used in other included stud-
ies [161, 163, 164] and was the also only study to dem-
onstrate an increase in pre-exercise plasma ­NO3- or any
marker of nitric oxide synthesis (Additional Material
3). Despite increases in submaximal tissue oxygenation,
Bailey et al. [162] indicated minimal effects on exercise
performance, oxygen consumption or oxygen uptake
kinetics, and no other studies noted improvements
in internal performance indicators. Thus, no effect of
watermelon juice consumption on exercise performance
was observed overall, or within any individual study.
Areas for future research
Sex differences in effects of nitric oxide‑related
supplementation
While trivial effects were evident for the consumption
of ­NO3- and polyphenol-rich foods, neither nutrient was
effective in enhancing female endurance exercise per-
formance (g=0.0 and 0.01, respectively) based on data
from four trials. Polyphenol mixed-sex trials also demon-
strated no effect on exercise performance, whereas trials
of males only demonstrated small, significant effects. This
Page 20 of 28
finding is in agreement with that of a polyphenol meta-
analysis by Somerville, Bringans and Braakhuis [174],
who noted an attenuated effect (magnitude not specified)
of exercise performance in studies that included both
females and males.
Regarding the lack of efficacy of ­NO3- consumption for
improving exercise performance in females, it is difficult
to determine whether the lack of effect is attributable to
biological differences between the sexes or the contexts
of the studies. All four trials that assessed the effect of
­NO3- on exercise performance in females assessed time-
trial performance, and were predominantly conducted
in high-level athletes, with two studies conducted in
participants classified as PL4 [62] and PL5 [70], and
one study conducted in national-level water polo play-
ers. Hence, the absence of effects in these trials may be
attributable to the decreased efficacy demonstrated for
both time-trial performance and fitter athletes within
this review, although an included study by de Castro,
de Assis Manoel, and Machado [59] found no effects in
untrained females. Overall, the small number of female
trials, particularly in less well-trained athletes, combined
with the similar effect sizes between mixed-sex (although
these were predominantly comprised of males) trials
and male-only trials, makes it difficult to infer whether
there are genuine sex differences in the response to
­NO3- consumption.
If sex differences in the response to polyphenol and
­NO3- consumption do exist, several potential mecha-
nisms may be responsible. Females have increased
endothelium-dependent dilation [28], which may be
attributable to elevated levels of plasma nitrite as a result
of enhanced N ­ O3--reducing activity by oral bacteria [194]
and an augmenting role of estrogen in eNOS expression
[27]. The increased proportion of slow-twitch muscle
fibres in females [195] may be an additional factor, given
that ­NO3- consumption proposedly confers its ergogenic
potential primarily via effects on fast-twitch muscle fibres
[8]. Females also appear to have reduced levels of oxida-
tive stress compared with males, which may be due to a
variety of factors including the antioxidant properties of
estrogen [30]. While these factors may provide mecha-
nistic underpinnings for the reduced response observed
in females, studies in females are underrepresented in
the literature, comprising only 18% of the participants
within the meta-analysis and female-only studies were
even more limited. Thus, further research of potential sex
differences in the response to ­NO3- and polyphenol con-
sumption is certainly still warranted.
Effects of exercise intensity on responses to supplementation
Metabolic acidosis is proposed to inhibit NO synthesis
through the NOS-dependent pathway while enhancing
 d’Unienville et al. J Int Soc Sports Nutr (2021) 18:76
synthesis through the NOS-independent pathway [196],
which would suggest distinct intensity-dependent effects
of ­NO3- and polyphenol consumption. However, there
appeared to be no moderating influence of test duration
on effect sizes for TT or TTE tests following both N ­ O3-
and polyphenol consumption. Several studies assessed
the effects of ­NO3- and polyphenol consumption across
multiple exercise intensities, with mixed results. Investi-
­ O3- on TTE at increasing exercise
gating the effects of N
intensities, Kelly et  al. [67] reported decreasing effect
sizes (Hedge’s g = 1.06, 0.64, 0.62 and 0.48, respectively)
as intensity increased and no significant effect at maxi-
mal intensity (V̇O2peak). Similarly, [151] Trexler et  al.
found significant TTE improvements at 90% and 100%,
but not 110%, of peak aerobic velocity following pome-
granate extract consumption. Two studies conducted
multiple distance TTs following ­NO3- consumption, with
Shannon et al. [85] noting positive effects in a 1.5 km but
not 10 km running TT, whereas no differences between
improvements were seen between 4 and 16.1 km cycling
TT performance by Lansley et  al. [71]. Regarding inter-
mittent performance, Wylie et  al. [95] found significant
increases in mean power output during 24 repeated six-
second sprints, but no effect on exercise performance
across six 60-second efforts. Overall, these studies do not
provide a clear indication of whether the effectiveness of
consuming foods that promote synthesis of nitric oxide
may be influenced by the intensity/duration of the per-
formance test.
Potential influence of other dietary factors
The bioavailability of polyphenols is dependent on sev-
eral factors including the phytochemical and overall
composition of their food source matrix, background diet
and genetic factors, particularly intestinal microbiota [25,
191]. Most included studies increased polyphenol intake
through supplementation with a specific product or food,
rather than a more holistic dietary intervention that
increases polyphenol intake from various food sources.
Notable exceptions included Knab et al. (2014), who uti-
lised a fruit and vegetable juice blend powder, while a
study by Ueberschlag et al. (2016) used Protandim, a mix
of milk thistle, bacopa, ashwagandha root, turmeric and
green tea, but no significant performance improvements
were seen in either of these studies. There is evidence
that interactions between specific combinations of poly-
phenols and their food sources can have both synergistic
and inhibitory effects on antioxidant activity [18, 197],
but whether this may influence exercise performance is
not yet established. It has also been postulated that the
co-ingestion of N­ O3- and polyphenols could have a syn-
ergistic effect on nitric oxide status [18, 191], which may
contribute to increased efficacy of N ­ O3- administered
Page 21 of 28
as beetroot juice in comparison to sodium N ­ O3- [198],
although limited evidence is available in support of this
[17]. Baker et  al. [199] found significant improvements
in TT performance following a four-day Mediterranean
diet intervention where consumption of olive oil, fruits,
nuts, seeds and vegetables was significantly increased,
although there were also changes in intake of fish and red
meat. Thus, while food-derived polyphenol consumption
was shown to have significant overall benefits within this
review, further research is still warranted into whether
polyphenol consumption through a more holistic, whole
foods-based approach may still enhance endurance exer-
cise performance and whether the co-consumption of
polyphenols ­NO3--rich foods could confer any additional
ergogenic effects.
Given the potential interactions of N ­ O3- and polyphe-
nols with other dietary factors, it is also of interest as to
whether nitric oxide-related supplements may affect the
responses to other ergogenic aids such as caffeine. Four
beetroot studies investigated the effects of beetroot juice
both alone and in combination but indicated that beet-
root juice had neither a positive effect independently,
nor did it influence the ergogenic effect of caffeine [62,
63, 70, 80]. These studies were all conducted on highly-
trained athletes (all ≥PL4) and three of the four studies
assessed performance via a TT, with both factors having
reduced ergogenic effects within this review. No included
polyphenol studies investigated any interactional effects
with caffeine, although an excluded study investigating
the effects of consuming coffee rich in caffeine and chlo-
rogenic acid demonstrated no effects on TT performance
despite comparison against a decaffeinated placebo [200].
Effects on training adaptations
While it appears that ­NO3- and polyphenol consump-
tion can enhance endurance exercise performance, it is
also important to evaluate whether their consumption
may influence an athlete’s response to training. While
most studies controlled each individual’s training per-
formed during the interventions, several studies inves-
tigated responses to polyphenol consumption during a
training program. ­NO3--rich beetroot juice consumption
enhanced adaptions to sprint interval training [35, 89],
which may be related to enhancing exercise capacity dur-
ing training [201], as well as remodelling of skeletal mus-
cle towards oxidative phenotypes [35], although this has
not been consistently found [89]. While Kuo et al. [134]
found no effects of green tea consumption on its own,
an ergogenic response was shown when it was combined
with an endurance training protocol. This interactional
effect has not been replicated by other polyphenols stud-
ies however, with no discernible effects evident following
consumption of ginger and New Zealand blackcurrant in
d’Unienville et al. J Int Soc Sports Nutr (2021) 18:76
combination with high-intensity interval training [128,
140], although both of these studies were in females. It
has been proposed that there is a hormetic relationship
between the oxidative stress induced by training and
subsequent adaptations, whereby an optimal amount of
oxidative damage is needed to maximise training adap-
tations, whereas inadequate or excess levels can both
result in negative responses [202]. Indeed, chronic anti-
oxidant supplementation with vitamin E has been linked
to impaired performance [203], and varied responses
have been demonstrated following vitamin C supple-
mentation [204]. Presently, the lack of negative effects
overall and in response to the same training suggests
that consumption of polyphenol and ­NO3--rich foods
does not impair adaptations to training, although their
ability to augment these adaptations requires further
investigation.
Limitations
Polyphenol inclusion criteria
One limitation of identifying polyphenol-rich foods
within the present study was that there is no set defini-
tion of what this entails, and often studies did not spec-
ify phenolic content or reported only the composition
of specific polyphenolic compounds and total phenolic
content was unclear. This issue was identified during
the development of the search strategy, and thus it was
decided that a separate meta-analysis would also be
conducted for studies that did report phenolic content.
However, as seen in Table  6, results largely did not dif-
fer between studies that did and did not report phenolic
content.
Several foods featured in the included studies also con-
tained other bioactive compounds (e.g. other antioxi-
dants such as polysaccharides, carotenoids, ginsenosides,
vitamins C and E) that may confound the effects of their
phenolic content. While there are some exceptions [184],
in many such foods, antioxidant activity remains very
strongly linked to total phenolic content [178, 205–207],
suggesting that polyphenols are the primary driver of
their antioxidant properties. Also, in the interest of eval-
uating the effectiveness of these foods overall and main-
taining ecological validity, foods were deemed eligible
unless such compounds were added to foods separately.
Risk of Bias
In contrast to older reviews that used the previous
Cochrane RoB Tool, no studies within this review were
classified as low risk using the RoB Tool 2.0, reflecting
its more explicit, detailed requirements that were not
aligned well with sports nutrition and exercise science
reporting standards. Future publications should provide
more specific details to better ascertain risk, particularly
Page 22 of 28
regarding specification of the randomisation process
used, allocation sequence concealment, compliance with
dietary interventions, and reference to pre-specified data
analysis protocols, as these were poorly addressed by
included studies.
Conclusion
Consumption of foods rich in ­N O3- and polyphenols
may provide trivial beneficial effects for endurance
exercise performance, while consumption of foods
rich in L-citrulline, currently limited only to studies
of watermelon juice, does not appear to affect per-
formance. Beetroot juice has been extensively stud-
ied and its N ­ O3- content confers ergogenic effects
in various exercise types in populations that are
not considered well-trained. Other food sources of
­N O3- require further investigation of their ergogenic
capacity. Food-derived polyphenols appear to have
the potential to enhance TT performance to a simi-
lar extent as beetroot juice, although more research is
needed regarding its efficacy for use in highly trained
athletes. No effects were evident for the consump-
tion of polyphenols from New Zealand blackcurrant,
cocoa, ginseng, green tea and raisins, but significant
benefits were shown for the consumption of grape,
beetroot ­(NO3--depleted), French maritime pine,
Montmorency cherry and pomegranate across mul-
tiple studies. However, caution should be exercised
in translating these ergogenic effects to other food
sources of polyphenols, as there seems to be consider-
able variation in the effects between foods that cannot
be attributed to differences in total phenolic content
or key polyphenolic compounds. Distinct responses
to ­N O3- and polyphenol supplementation were also
observed between males and females, with females
not demonstrating any benefit for exercise perfor-
mance. This may be due to sex-based differences in
nitric oxide synthesis, vascular function and oxidative
stress, and/or the limited number of female studies
and the training status of the participants. N­ O3--rich
food consumption increases nitric oxide synthesis,
and its physiological effects are more clearly linked
to increases in muscle oxygen delivery and exercise
efficiency, whereas polyphenol-rich foods have less
clearly established effects on nitric oxide synthesis,
vascular function and physiological variables dur-
ing exercise. Future studies should evaluate effects
of ­N O3- and polyphenol consumption on training
performance and adaptations, as well as optimising
protocols for consuming polyphenol-rich foods, and
establishing the individual and test-related (e.g. inten-
sity) factors that influence the ergogenic response to
consuming ­N O3- and polyphenol-rich foods.
 d’Unienville et al. J Int Soc Sports Nutr (2021) 18:76
Abbreviations
GXT: graded exercise test; IGXT: intermittent graded exercise test; ITT: intermit-
tent time-trial; ITTE: intermittent time to exhaustion; k: number of trials; km:
kilometre; n: sample size; NO2-: nitrite; NO3-: nitrate; PL: performance level; Qb:
between-group Q-statistic; SMD: standardised mean difference (Hedge’s g); TT:
time-trial; TTE: time to exhaustion.
Supplementary Information
The online version contains supplementary material available at https://​doi.​
org/​10.​1186/​s12970-​021-​00472-y.
Additional file 1. Database search strategies. Verbatim search strategy
used in each database.
Additional file 2. Cochrane Risk of Bias Tool 2.0 Summary. Assessments of
overall and domain-specific bias of included studies.
Additional file 3. Study Characteristics and Summary Table. Description:
Key characteristics and results of included studies.
Additional file 4. L-citrulline meta-analysis and sub-group analyses.
Description: L-citrulline meta-analysis and sub-group analyses table.
Authors’ contributions
NMAdU, AMH, AMC, MJN and JDB conceived the review, all authors con-
ducted title and abstract screening, NMAdU and HTB conducted full-text
review, data extraction and risk of bias assessment, NMAdU drafted the
manuscript, which was critically revised by all authors. The author(s) read and
approved the final manuscript.
Funding
NMAdU and HTB are supported by Australian Government Research Training
Program Scholarships. No other funding was provided.
Availability of data and materials
The datasets used and/or analysed during the current study are available from
the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Competing interests
NMAdU, AMH, AMC, MJN and JDB are currently conducting a randomised
controlled trial assessing the effects of consuming almonds, sultanas (raisins)
and cranberries on endurance exercise performance and recovery, which is
funded by a grant from the International Nut and Dried Fruit Council (INC)
Foundation. However, the INC did not provide support for this review and
were not involved in any aspect of its conception, collection, analysis or
interpretation.
Author details
1
 Allied Health and Human Performance, University of South Australia,
Adelaide, Australia. 2 Alliance for Research in Exercise, Nutrition and Activity
(ARENA), University of South Australia, Adelaide, Australia. 3 Clinical and Health
Sciences, University of South Australia, Adelaide, Australia.
Received: 11 August 2021 Accepted: 23 November 2021
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